Received: 8 September 2019 Revised: 6 March 2020 Accepted: 13 March 2020

DOI: 10.1002/clc.23364

REVIEW

Cardiac evaluation of young athletes: Time for a

risk-based approach?

Hamish MacLachlan1 | Jonathan A. Drezner2

1
Cardiovascular Sciences Research Centre, St
Georges University of London, London, UK
2
Department of Family Medicine and the
Center for Sports Cardiology, University of
Washington, Seattle, Washington
Correspondence
Jonathan A. Drezner, MD, Department of
Family Medicine and the Center for Sports
Cardiology, University of Washington, Seattle,
WA.
Email: jdrezner@uw.edu
Abstract
Pre-participation cardiovascular screening (PPCS) is recommended by several
scientific and sporting organizations on the premise that early detection of cardiac
disease provides a platform for individualized risk assessment and management;
which has been proven to lower mortality rates for certain conditions associated with
sudden cardiac arrest (SCA) and sudden cardiac death (SCD). What constitutes the
most effective strategy for PPCS of young athletes remains a topic of considerable
debate. The addition of the electrocardiogram (ECG) to the medical history and phys-
ical examination undoubtedly enhances early detection of disease, which meets the
primary objective of PPCS. The benefit of enhanced sensitivity must be carefully
balanced against the risk of potential harm through increased false-positive findings,
costly downstream investigations, and unnecessary restriction/disqualification from
competitive sports. To mitigate this risk, it is essential that ECG-based PPCS pro-
grams are implemented by institutions with a strong infrastructure and by physicians
appropriately trained in modern ECG standards with adequate cardiology resources
to guide downstream investigations. While PPCS is compulsory for most competitive
athletes, the current debate surrounding ECG-based programs exists in a binary form;
whereby ECG screening is mandated for all competitive athletes or none at all. This
polarized approach fails to consider individualized patient risk and the available
sports cardiology resources. The limitations of a uniform approach are highlighted by
evolving data, which suggest that athletes display a differential risk profile for
SCA/SCD, which is influenced by age, sex, ethnicity, sporting discipline, and
standard of play. Evaluation of the etiology of SCA/SCD within high-risk
populations reveals a disproportionately higher prevalence of ECG-detectable
conditions. Selective ECG screening using a risk-based approach may, therefore,
offer a more cost-effective and feasible approach to PPCS in the setting of
limited sports cardiology resources, although this approach is not without impor-
tant ethical considerations.

KEYWORDS

athlete, ECG, risk, screening, sports cardiology, sudden cardiac death

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.

Clin Cardiol. 2020;1–9. wileyonlinelibrary.com/journal/clc 1

2 MACLACHLAN AND DREZNER
1 | I N T RO DU CT I O N
The sudden death of a young athlete is a devastating event, particularly
when one considers its unexpected nature and the considerable number
of life-years lost for an individual who is deemed to represent the health-
iest segment of our society. As such, these highly emotional events are
afforded significant visibility and galvanize discussion between physicians
and the lay community with an emphasis on improving our understand-
ing of the conditions predisposing to sudden cardiac arrest (SCA)/sudden
cardiac death (SCD) and the development of effective preventative
strategies.
Exercise is a recognized trigger for ominous ventricular tachyar-
rhythmias in predisposed athletes that harbor a hereditary or congenital
cardiac abnormality associated with SCA/SCD. Naturally, there is a desire
to identify these at-risk conditions on the premise that the majority of
these athletes can be detected during life through pre-participation
cardiovascular screening (PPCS). The primary objective of PPCS is to
identify underlying cardiac disorders predisposing to SCA/SCD with the
intent to reduce morbidity and mortality by mitigating risk through indi-
vidualized, patient-centered, and disease-specific medical management.1
There is widespread agreement that SCA/SCD in young athletes is an
important public health issue, and that effective prevention requires early
detection of these cardiac conditions. Compelling evidence for its justifi-
cation has led the American Heart Association (AHA) and the European
Society of Cardiology (ESC) to both advocate PPCS for young athletes
on medical, legal, and ethical grounds.
Determining what constitutes the most effective PPCS strategy
for young athletes has created an intense debate regarding the need
and feasibility of electrocardiogram (ECG)-based screening programs.
Critics of a widespread ECG-based screening program highlight con-
cerns related to the lack of robust evidence for its efficacy to reduce
athlete fatalities, reliability of outcomes (false-positives), and overall
cost. Proponents of ECG screening recognize the relative failure of
the history and physical examination to meet the primary objective of
PPCS, specifically to detect athletes with at-risk cardiac conditions,
and the wealth of evidence demonstrating the high false-positive
response rate and very low positive predictive value of symptom and
family history questionnaires.2
The paradigm of ECG screening has been debated in a binary “all
or nothing” form, whereby programs are mandated to include ECG for
all young athletes, or none at all. These polarized options contradict
the fundamental approach to preventative medicine, which ordinarily
requires assessment of individualized patient risk and the available
medical resources. This article will address the current landscape of
PPCS and review the epidemiological data of SCA/SCD in young ath-
letes, which may support a novel risk-based approach to PPCS.
2 | ETIO LO GY OF SCA/SCD I N Y OU NG
ATHLETES
Understanding the etiology of SCA/SCD is paramount to inform
the development of an effective preventative strategy for young
athletes. Hypertrophic cardiomyopathy (HCM) is historically recog-
nized as the leading cause of SCA/SCD in the United States while
in Italy, arrhythmogenic cardiomyopathy predominates. Genetic
variation, ascertainment bias of identified cases, and variable
criteria and expertise for pathological diagnosis contribute to these
regional discrepancies. More recent data suggest that autopsy neg-
ative sudden unexplained death in athletes with presumed SCD
may be more prevalent than previously thought. Data from a spe-
cialist cardiac pathology center in the United Kingdom in 357 ath-
letes has shown that in up to 42% of cases, the heart is structurally
normal, and when the toxicology screen is negative, these deaths
are classified as sudden arrhythmic death syndrome (SADS).3 This
finding also has been demonstrated in studies of college athletes in
the United States,4 military recruits,5 and the general population
(nonathletes).6 These cases are largely attributed to primary cardiac
ion channel disorders such as the Brugada syndrome, long QT syn-
drome, and catecholaminergic polymorphic ventricular tachycardia,
or congenital accessory pathways such as ventricular preexcitation.
Accurate diagnosis following SADS, enhanced by postmortem
genetic testing and standardized autopsies performed by experi-
enced cardiac histopathologists, is essential when we consider that
subsequent evaluation of SADS families leads to a diagnosis of an
inherited cardiac condition in up to 50% of cases.7
3 | I N C I D E N C E OF SC A / S C D I N Y O U N G
ATHLETES
SCA/SCD is the leading medical cause of death in young athletes
during sports and exercise.4 Current estimates for the incidence of
SCA/SCD in young athletes vary widely. This variation is accounted
for by differing methodology and heterogeneous population compari-
sons. An accurate calculation of the incidence of SCA/SCD requires a
precise numerator (number of cardiac events per year) and an exact
denominator (number of athlete participants per year) in the popula-
tion studied. Inaccurate assessment in either of these accounts for
unreliable estimates of incidence. The majority of studies have utilized
passive collection methods through retrospective review of media
reports, electronic databases, and insurance claims, which are limited
by ascertainment and confirmation bias that may significantly under-
estimate incidence calculations. Mandatory reporting systems of ath-
lete deaths with accurate population demographics offer the most
reliable method of case identification and incidence calculations,
although very few currently exist.
Survival rates of SCA in athletes have significantly improved
following more widespread implementation of emergency response
plans and automated external defibrillators (AEDs).8,9 It is therefore
essential that both nonsurvivors (SCD) and survivors (SCA) are
included in estimations of incidence. Studies failing to do so provide a
worrying misconception of declining rates of SCD where the actual
rate of life-threatening cardiac events is unchanged and the purpose
of identifying athletes with at-risk disorders through PPCS remains of
critical importance. Other methodological factors, which influence
MACLACHLAN AND DREZNER
incidence estimates include the definition of an “athlete,” the inclusion
or exclusion of adverse events at certain times or locations (some
studies include events which occur only during exercise), and finally
the age range of the study population.
Appreciation of these methodological inconsistencies is particu-
larly important when scrutinizing the validity of estimates drawn from
larger systematic reviews. Mohaneney et al recently evaluated the
global incidence of sports-related SCD in young athletes through a
meta-analysis of 21 studies which included 1994 cases of sports-
related SCD over 430 million athlete-years (AY). The pooled incidence
of SCD reported was 0.72 per 100 000 AY. However, the significant
variation of reported incidence (0.09-13.09 per 100 000 AY) across
the 21 studies is attributable to considerable heterogeneity in study
methodology as described above, and evenly weighting studies with
both poor and robust methodology is likely to bias the analysis and
underestimate the pooled incidence of SCD.
Harmon et al performed a comprehensive review of studies that
have examined the incidence of SCA/SCD in young athletes.10 The
objective of this review was to assess the methodological strengths
and weaknesses used to arrive at estimates, compare studies with
estimates of similar populations, and arrive at an approximation of
incidence based on the available evidence. The incidence of SCA/SCD
across all 28 studies varied from 1:3000 to 1:917 000 AY. However,
studies with higher methodological quality yielded a higher incidence
10
ranging from 1:40 000 to 1:80 000 AY. This systematic review that
accounts for differences in study methodology has led to a generally
accepted annual incidence of SCA/SCD in young athletes as
1:50 000 AY.
The underpinning of the screening debate is centered on the per-
ceived incidence of SCD in young athletes. The screening community
F I G U R E 1 Annual risk of SCD in
young athletes.11 Annual risk of SCD
in athletes from Veneto, Italy,12 and
Minnesota,13 and more recent
incidence data in NCAA college
athletes,4 UK Premier league soccer
players,14 and US military personnel.5
Graph adapted from Drezner et al.11
CV, cardiovascular; NCAA, National
Collegiate Athletic Association; SCD,
sudden cardiac death
3
must interpret the validity of incidence estimates with a keen eye on
the rigor of the methodology used to obtain them. Further studies
using data from mandatory reporting systems and inclusive of all
deaths and survivors are clearly warranted if we are to improve our
understanding of the magnitude of SCA/SCD in young athletes.
4 | A R E C E R T A I N P O P U L A T I O N S OF
ATHLETES AT HIGHER RISK OF SCA/SCD?
Evolving data supports a differential risk profile for SCA/SCD in cer-
tain populations of athletes (Figure 1).
The incidence rate of SCA/SCD in athletes appears to be deter-
mined by age, sex, race, sporting discipline, and standard of play
(Figure 2). Athletes over 35-years old are at 5 to 10 times higher
risk than their younger counterparts.10 Risk in this age group is
most commonly attributed to the higher prevalence of ischemic
heart disease and established cardiovascular (CV) risk factors (obe-
sity, hypertension, diabetes mellitus, smoking, and hyperlipidaemia).
It is well recognized that these CV risk factors at a young age are
associated with increased CV morbidity and mortality in later life;
but could they promote a more immediate risk of SCA? Jayaraman
et al recently evaluated the association of standard CV risk factors
and SCA in 3775 young individuals (aged 5-34 years).15 Interest-
ingly, standard CV risk factors were identified in 58% of SCA cases.
One might expect this figure to be lower in a selected cohort of
young athletes; however, these findings remain relevant to public
health policy, and primary preventative approaches which should
include educating and treating young athletes with risk factors of
CV disease.
4 MACLACHLAN AND DREZNER
F I G U R E 2 Risk factors for sudden cardiac arrest and death in
young athletes
Clear sex differences exist, with males reported to be at 3 to
10-fold higher risk compared to female counterparts in competitive
sport, and up to 20-fold higher risk in recreational sport.16 The rea-
sons for this are poorly understood. The modern era has seen a signifi-
cantly higher proportion of competitive female athletes without a
parallel increase in mortality rates. It is thought that these sex differ-
ences are determined by a complex interplay between genetic, pheno-
typic, hormonal, and possibly environmental mechanisms.
Two prominent studies of young athletes in the United States
have mirrored these findings with regard to sex, but also suggest that
the risk of SCA/SCD is further determined by the athlete's race, sport-
ing discipline, and standard of competition. Garberich et al recently
evaluated the demographics of 842 young athletes with autopsy con-
firmed SCD within a large forensic registry of competitive US athletes
over a 32-year period. The incidence of SCD in male athletes
exceeded that in female athletes by 6.5-fold (1:122 000 vs 1:787 000
AY), while the risk in black athletes exceeded that in white athletes by
17
almost fivefold (1:13 000 vs 1:61 000 AY).
Harmon et al evaluated 79 cardiac-related deaths taken from a
large database of National Collegiate Athletic Association (NCAA) ath-
letes over 10 years which included 4 242 519 total AY of participa-
tion. It is worth noting that all athletes had previously undergone
PPCS predominantly without an ECG and incidence rates did not
include survivors of SCA. The overall incidence of SCD in NCAA ath-
letes was 1:54 000 AY. Again, male athletes were at threefold higher
risk than female counterparts (1:38 000 vs 1:12 2000 AY) and black
athletes were threefold higher risk than white athletes (1:21 000 vs
1:68 000 AY). Breaking these results down further, male-black
athletes demonstrated a risk of 1:16 000 AY, male basketball players
1:9000 AY, and male NCAA division I basketball players a risk of
1:5200 AY. Men's basketball represents only 4% of male NCAA ath-
letes, but almost 20% of all SCD cases. Male basketball and American-
football players together represent 23% of all male NCAA athletes but
50% of all SCD cases. In combination, these two sports (basketball
and American-football) consistently account for the majority (50%-
61%) of all identified cases of SCA/SCD in the United States.4,18 In
the United Kingdom, elite adolescent and young adult soccer players
also demonstrate a high incidence of SCD (1:14 800 AY).14
In a Canadian study, Landry et al undertook a retrospective
5-year analysis of a population-based registry of out-of-hospital SCA
occurring in young athletes.19 They identified 16 athletes who had
experienced SCA during competitive sport, which suggested a low
absolute risk of SCA (0.76 cases per 100 000 or 1:132 187 AY). This
figure is largely determined by the extremely low number of SCA
cases (0.29 per 100 000 AY) in ice hockey players who accounted for
a third of the overall study population (Table 1). Once again, evalua-
tion of incidence according to type of sport suggests that high-risk
groups exist; including those athletes who engage in Jujitsu (21.1 per
100 000 AY), soccer (5.9 per 100 000 AY), and basketball (3.4 per
100 000 AY).19 The mechanisms for which these athlete subpopula-
tions are at disproportionately higher risk remains unclear.
5 | CURRENT PPCS PRACTICE
The AHA recommends that all athletes are screened with a 14-element
assessment via a medical history and a physical examination. Secondary
evaluation is considered for any athlete with a positive response to any
one of the 14 elements. The AHA's pragmatic approach is widely prac-
ticed but limited when one considers that up to 80% of young athletes
are asymptomatic prior to their SCA/SCD.21,22 Furthermore, the major-
ity of conditions associated with SCA/SCD are seldom associated with
abnormal CV findings on physical examination. Indeed, a direct compar-
ison of the performance of the AHA 14-element evaluation vs ECG in
the CV screening of adolescent athletes demonstrated that the sensitiv-
ity (18.8%), specificity (68.0%), and positive predictive value (0.3%) of
the AHA 14-point evaluation was substantially lower than the sensitiv-
ity (87.5%), specificity (97.5%), and positive predictive value (13.6%) of
ECG.2 Other studies comparing screening strategies, some of which
were undertaken in dedicated centers with PPCS experience, have con-
sistently highlighted the poor performance of the medical history and
physical examination when used in isolation. A recent meta-analysis of
15 studies comparing strategies in 47 137 athletes revealed that the
ECG was five times more sensitive than the medical history and
10 times more sensitive than physical examination for detecting ath-
letes with conditions associated with SCA/SCD.23
The weight of scientific evidence has led to widespread agree-
ment that ECG enhances the detection of conditions associated
with SCA/SCD to better meet the primary objective of PPCS. Screen-
ing with ECG may identify more athletes with at-risk disease, but
does this equate to saving lives? Limited long-term morality data is
MACLACHLAN AND DREZNER 5

TABLE 1 Incidence of sudden cardiac arrest among competitive athletes in Ontario and Canada

Percent of total AY of observation,

Sporwt athlete population SCD, 2009 to 2014 SCD per 100 000 AY Incidence of SCD (AY) 2009 to 2014
Jujitsu 0.3 2 27.10 1/3690 7380
Soccer 3.2 4 5.92 1/16 898 67 590
Rugby 1.3 1 3.77 1/26 520 26 520
Basketball 2.7 2 3.45 1/29 004 58 008
Baseball 1.8 1 2.63 1/38 058 38 058
Race eventsa 20.8 4 0.90 1/110 073 440 292
Ice hockey 33 2 0.29 1/349 170 698 340
All sports 100 16 0.76 1/132 187 2 114 994
a
Includes endurance events such as triathlons and marathons.
Abbreviations: AY, athlete-years; SCD, sudden cardiac arrest.
Source: Adapted from Landry et al19 and D'Silva et al.20

available to support the efficacy of an ECG-based PPCS strategy.12
Italy introduced a mandatory state sponsored PPCS program in 1982.
This program requires all young competitive athletes to undergo
assessment with a health questionnaire and a resting 12-lead ECG
prior to clearance for sports participation. Mortality data over a
25-year period (1979-2004) demonstrated that the incidence of SCD
in young athletes reduced by almost 90%. By contrast, the incidence
rate of SCD in unscreened nonathletes remained unchanged over the
same time period. Investigators attributed the mortality trends to the
greater number of cardiac conditions, specifically cardiomyopathies,
identified by an ECG-based PPCS. This decline in SCD correlated with
the number of athletes disqualified from competitive sport, which
doubled over the screening period. This seminal study suggests that
systematic PPCS of young athletes with ECG significantly reduces
mortality rates via identification and disqualification of individuals
with previously undiagnosed cardiomyopathies.
Only one other study provides long-term mortality data in com-
bination with findings from baseline PPCS. Malhotra et al reported
findings in 11 168 elite adolescent soccer players screened at a
mean age of 16.4 years with a health questionnaire, physical exami-
nation, ECG, and echocardiogram, and followed for a mean of
10.6 years. Forty-two athletes (0.38%) were identified with a car-
diac disorder associated with SCA/SCD. Only four of these athletes
(9.5%) presented with symptoms and/or findings on physical exam-
ination, whereas 36 (86%) had an abnormal ECG. Athletes with
pathological cardiac disorders received disease-specific medical
management, procedural interventions, and exercise restrictions as
indicated to mitigate their risk. Two athletes with HCM who ret-
urned to sport against medical recommendations died, while
SCA/SCD was potentially averted in 40 of 42 athletes optimally
14
managed after early detection of a pathological cardiac disorder.
Overall, eight athletes died an average 6.8 years from their screen-
ing evaluation. Six of these eight deaths were attributed to cardio-
myopathy. One must acknowledge that the ECG performed only
once at age 16 failed to detect a critical proportion of athletes who
subsequently died from cardiac disease. This limitation may be
attributed to the imperfect sensitivity of ECG,24 or more likely that
cardiac pathology was yet to manifest with ECG anomalies, espe-
cially in cases of cardiomyopathy where phenotypic expression of
disease in genetically predisposed individuals often occurs in late
adolescence and early adulthood.
This raises the important issue regarding the frequency and
timing for PPCS when one considers the variable age at which certain
conditions manifest on ECG. The optimal age to introduce PPSC for
athletes remains largely uncertain. Most consensus guidelines suggest
PPCS start at age 12 when pubertal maturation and the expression of
many disorders associated with SCD may begin.1,25,26 What is more
certain, and supported by the findings of Malhotra et al, is that screen-
ing should be repeated at regular intervals for the timely identification
of phenotype progression. This is reflected in the ESC's recommenda-
tion that athletes should undergo regular ECG screening at minimum
every 2 years.25
While outcome-based studies remain limited and the natural his-
tory of conditions associated with SCA/SCD remains largely
unknown, PPCS inclusive of ECG is further supported by disease-
specific data, which demonstrates that early detection in conjunction
with individualized risk stratification and management lowers mortal-
ity rates for certain cardiac conditions associated with SCA/SCD,
including HCM and long QT syndrome.27,28 Consequently, the ESC
recommends PPCS for all young athletes with the routine inclusion
of ECG.
The ESC's uniform approach in favor of ECG screening for all
young athletes raises numerous practical limitations, which warrant
careful review. The ECG will not detect all conditions, which predis-
pose athletes to SCA/SCD. The ECG may be normal in up to 10% of
athletes with HCM, 70% who are genotype positive for long QT syn-
drome, and 90% with premature coronary artery disease. Further-
more, the resting ECG is normal in almost all individuals with
anomalous coronary arteries, catecholaminergic polymorphic ventricu-
lar tachycardia, and aortopathies. These false-negatives may result in
false reassurance for a small proportion of athletes that harbor CV
conditions associated with SCA/SCD, but the rate of false-negative
screens is substantially lower than if using the less sensitive evaluation
of history and physical examination alone.
6 MACLACHLAN AND DREZNER
False-positive ECG findings are another important limitation to con-
sider. Regular exercise leads to a constellation of electrical and structural
cardiac alterations which collectively form the phenotype of the “ath-
lete's heart.” These physiological changes manifest as electrical changes
on the athlete's ECG and, in some cases, mimic those observed in
patients with cardiomyopathy. A notable example of this is the relatively
high prevalence of anterior T-wave inversion in black male athletes and
some adult endurance athletes. Misinterpretation of physiological ECG
findings leads to unnecessary downstream investigations and, in some
cases, inappropriate restriction from competitive sports. The financial
implications of false-positive findings provide the central argument
against national legislation for ECG screening in most countries.
6 | E C G I N T E R P R E T A T I O N I N A T H L ET E S
Standardized ECG interpretation criteria, first introduced by the ESC
in 2010, distinguished physiological adaptations from pathological
abnormalities, which led to improvements in interpretation accuracy.
Refinement of these criteria over the last decade has been facilitated
by a greater understanding of the athlete's heart. Contemporary
criteria have increasingly accounted for adolescent athletes, black eth-
nicity and some nonspecific electrical anomalies, including axis devia-
tion and voltage criteria for atrial enlargement, and sequentially
improved the specificity of ECG screening by driving down the false-
positive rate from 25% to less than 5%. In a study of 5258 NCAA ath-
letes, the false-positive rate was only 1.3% when experienced clini-
cians applied the latest international criteria (Figure 3) for ECG
interpretation in athletes.30 Application of contemporary criteria has
furthermore been associated with a 27% reduction in the cost of
screening without compromising the ability to detect athletes with
serious cardiac disease.31
Accurate ECG interpretation requires training and creates poten-
tial for inter-observer variation. This limitation was revealed in a
recent study, which demonstrated that cardiologists with no experi-
ence in PPCS were at least 40% more likely to categorize ECGs as
abnormal, compared to those with relevant experience.32 Moreover,
the inter-observer agreement rates among experienced cardiologists
were only moderate at best. These results highlight the need for
increased education in modern standards of ECG interpretation. Online
training modules reviewing the international criteria for ECG interpreta-
tion in athletes are freely available at: https://uwsportscardiology.org/
e-academy/. Efforts to improve the accuracy of ECG interpretation
using such methods have proved efficacious in several small studies
and hold promise for the future.33-35
These limitations underpin the need for ECG-based PPCS pro-
grams to be implemented by centers with a strong infrastructure,
using high quality control measures and physicians who are appropri-
ately trained in modernized ECG standards and supported by ade-
quate cardiology resources to guide the downstream investigations.
Unfortunately, there are very few countries worldwide that can realis-
tically provide such a platform for PPCS, which has driven the PPCS
community to consider alternative strategies.
7 | I S I T T I M E F O R A R I S K- B A S E D
APPROACH TO PPCS?
The argument for a risk-based approach to PPCS is supported by the
structure of established screening programs on both sides of the
Atlantic. The effectiveness of these programs, including those for
abdominal aortic aneurysm (AAA), breast, and colon cancer, is primar-
ily judged by their ability to detect disease, assuming perhaps without
definitive evidence that early detection will reduce mortality through
F I G U R E 3 The 2017 International
Consensus Standards for
electrocardiogram (ECG) interpretation
in athletes29
MACLACHLAN AND DREZNER
F I G U R E 4 Electrocardiogram-
detectable etiologies implicated in
117 cases of sudden cardiac arrest and
death in US competitive athletes (age
11-29 years)18
modern treatment. Furthermore, these programs consider higher risk
groups in their target population. Population-based screening pro-
grams for AAA were first established in the United States and United
36,37
Kingdom over 10 years ago. The prevalence of AAA increases
with age and region, and is four to six times higher in males compared
to female counterparts.38,39 Epidemiological data, which identifies
high-risk groups is taken into account by national screening commit-
tees, considering both programs restrict screening to men over the
age of 65 years. Additional risk factors including family history and
smoking status are respectively considered for breast cancer and AAA
screening programs in the United States.
Guidelines for the primary prevention of CV disease routinely rec-
ommend physicians to consider the individual's estimated risk of
adverse CV events as a guide to management decisions.40 This factor
is not considered in the current PPCS recommendations, which adopt
a “one size fits all approach,” despite several incidence studies provid-
ing robust evidence that certain athletic groups are at higher risk of
SCA/SCD than others.
The American Medical Society for Sports Medicine (AMSSM)
recently proposed a new PPCS framework, which considers the indi-
vidual risk of the athlete as well as physician expertise and available
cardiology resources for accurate ECG interpretation and the second-
ary evaluation of ECG abnormalities.1 Following careful review of the
current evidence and existing knowledge gaps, the task force rec-
ommended that physicians should consider more intensive screening
strategies, such as ECG screening, for high-risk athletes.
The AMSSM's risk-based framework is supported by the outcome
of a recent surveillance study of young athletes in the United States.
Peterson et al prospectively evaluated the etiology of SCA/SCD cases
in the United States through a national surveillance program over a
2-year period.18 Of the 117 cases with a confirmed diagnosis,
66 (56%) were identified with conditions that routinely demonstrate
ECG abnormalities (Figure 4). ECG-detectable conditions were identi-
fied in 33 of 62 (54%) white athletes, 23 of 37 (62%) black athletes,
7
and 13 of the 19 (68%) black basketball players. HCM was attributed
as the cause of death in 10% of white athletes, 30% of black athletes,
23% of male basketball athletes, and 25% of American-football ath-
letes. Although this study evaluated a relatively small cohort of ath-
letes, the findings suggest that ECG screening may be most effective
in higher risk groups where the proportion of ECG-detectable condi-
tions is disproportionately higher. Historical studies also highlight
HCM as one of the most common causes of SCD in young athletes; a
condition which manifests with abnormal ECG findings in up to 90%
of individuals.41 Larger prospective studies on the etiology of
SCA/SCD in athletes are warranted if we are to improve our under-
standing of what constitutes the most effective PPCS strategy for dif-
ferent athlete risk groups.
When ample sports cardiology resources are available, routine
use of ECG is possible in the PPSC of all athletes. However, reserving
the ECG for smaller populations of higher risk groups may offer a
more pragmatic approach for institutions that are not equipped with
the infrastructure and expertise to adequately support an ECG-based
model on a larger scale.
It is prudent, however, to consider the ethical issues of such an
approach. Institutions may argue that equivalent screening services
should be available to all athletes under their care and not differenti-
ated based on sex, race, or sport. This notion is supported by data
from France, Denmark, and the United States, which has demon-
strated that the incidence of SCD in recreational athletes and non-
athletic individuals, is higher than previously thought.17,42,43 While
recreational athletes are not required to undergo a PPCS prior to
sports participation, should these individuals be precluded from pri-
mary preventative strategies? Critics may also argue that a larger
number of epidemiological studies, using mandatory reporting sys-
tems for case identification, are warranted before we can reliably
define “high-risk” populations. However, nearly all preventive prac-
tices in medicine base the rigor of the screening evaluation on the
individual risk of the patient, and thus there is justification in the
8 MACLACHLAN AND DREZNER
setting of limited resources to provide the most intensive screening to
the athletes shown by current evidence to be at highest risk.
8 | C O N CL U S I O N S
The paradigm of PPCS has disputed the merits of an ECG-based pro-
gram as a binary “all or nothing” approach. This perspective fails to
consider the individual risk of the athlete and the available sports
cardiology expertise, which are essential to providing sound preventa-
tive care. Evolving data supports that certain populations of athletes
(male, black, basketball, soccer, or American-football players) are at
higher risk of SCA/SCD than others. The higher prevalence of ECG-
detectable conditions (most notably, cardiomyopathies) reported in
these high-risk groups, favors a more intensive approach with ECG
screening. In the setting of limited sports cardiology resources, a risk-
based approach may be the most pragmatic method to perform effec-
tive PPCS. While targeted screening for higher risk individuals has
precedence in other medical prevention programs, the merits, and fea-
sibility of this strategy must be carefully balanced against the ethical
concerns associated with screening only a subset of athletes and the
need for more definitive outcomes data.
ORCID
Hamish MacLachlan https://orcid.org/0000-0001-8682-6193
Jonathan A. Drezner https://orcid.org/0000-0003-3519-9120
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How to cite this article: MacLachlan H, Drezner JA. Cardiac
evaluation of young athletes: Time for a risk-based approach?
Clin Cardiol. 2020;1–9. https://doi.org/10.1002/clc.23364